https://leader.pubs.asha.org/article.aspx?articleid=2449230Comfort FoodThe calming powers of a stuffed bear: An SLP and OT use a technique for self-soothing and self-regulation to help people with cognitive impairments focus on—and enjoy—eating.2015-10-01T00:00:00FeaturesJoan Kelly Arsenault, MA, CCC-SLP, BCS-S

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Features | October 01, 2015

Comfort FoodThe calming powers of a stuffed bear: An SLP and OT use a technique for self-soothing and self-regulation to help people with cognitive impairments focus on—and enjoy—eating.

Joan Kelly Arsenault, MA, CCC-SLP, BCS-S, is managing member and owner of MassTex Imaging, LLC, which provides mobile dysphagia consultations throughout New England, and has more than 35 years of experience in pediatric and adult dysphagia. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; and 13, Swallowing and Swallowing Disorders. She lectures and conducts workshops in dysphagia on a national and state level. joan@massteximaging.com

Joan Kelly Arsenault, MA, CCC-SLP, BCS-S, is managing member and owner of MassTex Imaging, LLC, which provides mobile dysphagia consultations throughout New England, and has more than 35 years of experience in pediatric and adult dysphagia. She is an affiliate of ASHA Special Interest Groups 11, Administration and Supervision; and 13, Swallowing and Swallowing Disorders. She lectures and conducts workshops in dysphagia on a national and state level. joan@massteximaging.com×

Jane G. R. Musgrave, MS, OTR/L, owns Just Good Sense: Occupational Therapy Consultation and Training in Middleboro, Massachusetts. She lectures, conducts workshops and consults on occupational therapy, sensory modulation, and integrating recovery principles into hospital and residential settings. She is a consultant for the National Building Bridges Initiative and a faculty member of the National Center for Trauma Informed Care. jgrma22@gmail.com

Jane G. R. Musgrave, MS, OTR/L, owns Just Good Sense: Occupational Therapy Consultation and Training in Middleboro, Massachusetts. She lectures, conducts workshops and consults on occupational therapy, sensory modulation, and integrating recovery principles into hospital and residential settings. She is a consultant for the National Building Bridges Initiative and a faculty member of the National Center for Trauma Informed Care. jgrma22@gmail.com×

It was a teddy bear—a specially weighted one, but a teddy bear all the same—that started us on a collaboration to help people with a variety of disorders enjoy eating because they could once again swallow safely.

Our speech-language pathologist/occupational therapist (OT) collaboration incorporates sensory modulation—a technique in occupational therapy that helps people self-soothe and self-regulate. We bring the technique to people who experience swallowing and eating challenges due to a range of conditions, including intellectual disabilities, movement disorders, traumatic brain injury and dementia.

It’s important to consider sensory issues when assessing a person’s ability to swallow. Swallowing—whether for a dysphagia assessment or for eating—requires a calm, alert state. People with cognitive disorders may struggle to achieve this state when noises, sights, smells, tastes and other sensations interfere as they seek to orient themselves and to maintain their postural stability. They may become agitated or lethargic—or lose focus or become hyperattentive.

So, if sensory modulation can help people with such disorders swallow and eat safely, how can SLPs incorporate the technique in treatment?

Meet Enid

OTs use sensory modulation—techniques to raise the arousal level of people who are understimulated and to lower arousal for people who are overstimulated—to boost engagement, motivation, self-control and concentration and to ease agitation. It can help people sleep better, focus on tasks including eating, and engage in their own treatment.

One of us—Jane—is an OT who often uses Enid, an 8.5-pound, winter-white teddy bear stuffed with corn kernels, because holding a weighted object can be soothing and calming for some people. Jane was demonstrating the bear to clinical staff at a hospital when the staff were all called to attend to an agitated patient. She offered the bear to the nurse manager to try to calm the patient.

To the nurse’s surprise, the patient took Enid, and hugged the bear in her lap. It calmed her down and avoided the need for a restraint.

When the other of us—Joan, an SLP—heard this story from her friend Jane, she wondered if Enid would help a patient stop rocking during a modified barium swallow.

Enid’s story made us consider the role of sensory modulation during dining, eating and swallowing. It became clear that we could benefit from each other’s experience and knowledge base. Sensory techniques have typically been discussed in relation to pediatric feeding issues; why not turn our attention to how they could be used with dining and swallowing in adults—including those with intellectual disabilities, movement disorders, traumatic brain injury, mental health issues and dementia?

For many people with these conditions, the joy of eating diminishes: Food tastes and feels different in the mouth. Some people can’t maintain postural stability during eating, making it difficult for someone to feed them and increasing the risk of aspiration. Some people may rock during dining, making it difficult to get food in their mouths.

In a 2008 article in Physical Medicine and Rehabilitation Clinics of North America, Ianessa Humbert and JoAnne Robbins say that sensory function is understudied in the swallowing literature, despite its influence on the pharyngeal swallow response. It changes with age and is influenced by declining perception of spatial tactile recognition on the lip and tongue, diminished perception of viscosity in the oral cavity, poor oral stereognosis [tactile object recognition], and reductions in taste perception. They recommend that all forms of increased sensory stimulation or attention to a task be incorporated into swallowing treatment, especially given known diminishment in oral-pharyngeal sensation, attention and memory in older adults.

SLPs, however, primarily assess swallowing from the point when food or liquid is accepted into the oral cavity. We teach those who assist with eating how to use strategies to decrease the risk of aspiration and facilitate improved swallow function. We may use techniques such as cold or sour boluses to stimulate the swallow or decrease an oral hold pattern.

Thinking more broadly

Many of the sensory techniques SLPs use with adults center on the oral, pharyngeal and laryngeal areas. In addition, we need to consider the effect of the entire sensory system on eating and swallowing. And we should incorporate techniques to adjust the environment and food to help the patient modulate sensory information.

Questions to consider about the role of sensation in swallowing and eating include:

Could adding weight (like Enid the stuffed bear) improve stability to get food to the mouth or keep a patient from moving during a swallow study, as well as provide a calming state of alertness?

When we recommend removing distractions during meals or pacing food intake, can we give specific recommendations for how to accomplish this?

Can we alter the eating/dining environment to facilitate improved swallowing and oral intake outcomes, increase people’s ability to focus on eating, and facilitate improved attention span and learning?

Is the environment contributing to sensory overload that prevents a person from using skills he or she has?

What do we know about the patient’s taste preferences and how the person’s sensory dysfunctions may contribute to a longer oral hold or a lack of interest in eating?

Sensory modulation difficulties may be due to developmental delays, an acquired neurological deficit, a disorder on its own, characteristic of other neurological conditions, or even the result of certain medications. A sensory assessment may be indicated if a person displays:

Inability to remain focused during eating.

Oral defensiveness/hypersensitivity/food aversions.

Reduced oral sensation/awareness

Difficulty remaining calm and task-focused during meals.

Extraneous movement during meals.

Need for physical stabilization before focusing on eating/swallowing.

Poor concept of where his or her body is in space.

Food refusal or willingness only to eat foods with certain visual characteristics—for example, no moving foods such as gelatin; only foods cut into a particular size; no foods that touch one another.

Perception of aroma as unappealing, diminishing appetite.

Gagging, nausea or vomiting.

Inability to feel full and to stop eating.

What to do

People have an innate need to meet their sensory preferences: For example, you eat when you’re hungry and stop when you’re full.

OTs can help identify a person’s sensory preferences and work with the SLP to achieve the optimal balance of sensory arousal that allows the person to be calm and focused to optimize new learning.

If, for example, you know that the smell of cinnamon, the sound of soft music and the sight of lowered lighting are calming to someone, you can add these “sensory tools” into an event—such as a swallowing assessment—that might cause the person anxiety. Because these techniques can also help to increase a person’s ability to focus and attend to the task, they can be used during activities that require attention and focus: using compensatory swallowing strategies, pacing food intake and recognizing food in the mouth.

Winnie Dunn poses a model of sensory processing in her book “Living Sensationally: Understanding Your Senses.” Dunn, chair of the University of Kansas Department of Occupational Therapy Education, theorizes that people have four quadrants in their sensory lives: low registration, sensory seeking, sensory sensitivity and sensory avoiding.

A person who is sensory-seeking in the area of taste, for example, tends to enjoy sensory dining stimuli such as spicy foods, new foods and tastes, and variety in food choices, Dunn indicates. A person who is a sensory avoider may want to block out other sensory input and be more comfortable eating alone, sometimes preferring to do so. Someone who is sensitive in taste may find certain textures—such as peach skins or cottage cheese—unpleasant. Someone with low taste registration may not notice food temperature, for example, and may drink or eat something that is too hot, causing mouth burns.

Diners receive a host of sensory input: presentation of the food (visual); how the food smells and tastes; the sounds of chewing and biting (movement and auditory); the textures and temperature of the food (tactile); the movements of biting and chewing for correct positioning of the bolus on the teeth and to prevent tongue injury (tactile and movement); perception of bolus size and viscosity, which shifts physiology and muscle activity (tactile).

In organizing the dining experience in a care community, a clinician may want to consider all of the sensory input diners are likely to experience:

What are mealtimes like here? Does the dining room experience look and feel “normal,” or does it feel big, confusing and institutional?

Do mealtimes provide an opportunity for the sensory seeker and the sensory avoider to be successful?

Are mealtimes pleasantly social?

Are residents eating with people they like, or are they distracted or agitated by others with them?

Do staff approach residents at mealtime? Are they engaging them and calling them by name?

Does the dining room environment support people’s remaining abilities and allow them to feel success during the dining experience?

Would a sensory tool, such as weight placed in the lap, help a person having difficulty focusing during eating?

Does the dining room environment help to minimize extraneous movements or behaviors that interfere with safe eating?

People who need help calming or focusing to be able to eat may benefit from using a sensory tool. Calming tools include decaffeinated tea, warm liquids, sweet liquids, rocking in a rocking chair, soft music, appealing aromas and soft lighting. Grounding and focusing tools include a hand-held stress ball or gyroscope, a weighted pillow or stuffed animal (like Enid) held in the lap, arm and hand massages, sour or cinnamon candies, weighted blankets, and weighted or pressure vests.

Incorporating Enid the bear—and the concept of sensory modulation techniques—into swallowing diagnostics and dining recommendations has made a difference for many of our patients. With the use of weighted products, patients have been able to participate more fully in their swallowing evaluations, as their extraneous movements decrease and their attention to task increases. Patients holding the weighted item also can accept more trial foods during the study with improved oral lingual organization. We also are incorporating speech-language and occupational therapy recommendations in evaluation reports to enhance the dining experience.

SLPs can incorporate sensory modulation techniques into treatment sessions, evaluations and dining experiences, starting simply with asking the person or family members what helps the person calm down or focus. Asking about food preferences can also help enhance eating, particularly for people with dementia. Other suggestions include enhancing the visual appeal of modified diets; using an appropriate placemat (a colorful design to stimulate or a solid color to improve focus); and making or purchasing appropriate tools, such as weighted objects or stress balls.

Speech-language and occupational therapy collaboration is clearly a good way to enhance and foster the swallowing and dining outcomes for your patients.